A large trust in the Midlands commissioned Arden & GEM’s clinical support service to provide specialist pharmacist resource to deliver diabetes and hypertension clinics at one of their hospital sites to help manage complex patients.
A highly experienced and knowledgeable specialist pharmacist, with expertise in the management of patients with complex diabetes and hypertension, provided flexible, high-quality support for both inpatients and outpatients.
Over a 12-month period, over 700 patient reviews took place which has resulted in 1,675 interventions to increase treatment efficacy, improve patient safety, reduce hospital admissions and deliver drug cost savings for the local health economy.
Effectively managing long-term conditions has long been a key priority for the NHS. Proactive, high-quality care can enable conditions to remain stable, and patients to experience better health and an increased quality of life. While, for most patients, long-term condition management predominantly takes place in primary care, those individuals with complex or multiple conditions may be best supported within secondary care clinics.
Specialist pharmacists can bring valuable experience and expertise to multidisciplinary teams (MDT) in the care of patients with long term conditions. Following some internal changes in their pharmacy personnel, a large Midlands trust commissioned Arden & GEM’s clinical support service to provide specialist pharmacist resource with the right knowledge and skillset to deliver diabetes and hypertension clinics within a hospital site to help manage complex patients.
Following identification of a suitably experienced and knowledgeable pharmacist, with an independent prescribing qualification, the 12-month support project began in January 2021. An induction process was undertaken to ensure the pharmacist was aware of the Trust’s policies and procedures, and confident in using the clinical system. Relationships were also built with the pharmacy, diabetes and endocrinology, and renal teams.
Patients were referred to the clinics via consultants and nurses, as routine follow-ups following an initial appointment.
Hypertension outpatient clinics
During weekly hypertension clinics, almost 200 patients taking over 1,000 medications were reviewed, resulting in a number of interventions being made, most commonly to support patients to undertake appropriate home blood pressure (BP) monitoring and to review BP readings to support achievement of the patient’s BP target.
Management activities included:
- Drug initiation, titration, adherence and intolerances
- Lifestyle advice including dietary and activity
- Risk assessments.
Flexibility was built into the delivery model to meet the needs of the patient, with the majority of appointments undertaken as phone consultations (during the Covid-19 pandemic) and face-to-face appointments arranged where appropriate or required e.g. to take blood pressure readings. The pharmacist was also on hand to respond to medication queries from consultants, to support trainees and newly qualified staff, and help the ICB access funding for home blood pressure monitors.
For many of the patients attending the hypertension clinic, the key issues were medication intolerance and adherence. Once medication was working effectively and being taken as required, it was appropriate to discharge this cohort back to the care of their GP. Clinical letters were generated outlining key points and changes to ensure continuity of care.
Due to acute staffing pressures within the inpatient diabetes team, the support programme was modified to replace twice weekly outpatient diabetes clinics with inpatient ward reviews covering:
- Assessment of patients who had experienced hypoglycaemia
- Insulin initiation and dose titration
- Diabetics Ketoacidosis (DKA) management
- Patient counselling
- General advice and support to ward staff.
Patients were identified and prioritised for review by looking at referrals received by the inpatient diabetes team from ward staff and identifying hypoglycaemic episodes. Reviews were also undertaken on COVID-19 wards, where patients had poor sugar control or sugar levels has been destabilised by COVID treatments.
Outpatient clinics were resumed in March 2021, with a total of 510 inpatients and outpatients seen during ward reviews and clinics, and over 1,300 interventions implemented. Consultations were recorded on the Trust’s clinical system to ensure the consultation was accurately recorded within patient notes. Clinical letters were sent to both the patient and their GP to ensure good communication between all parties.
Flexibility in delivery
In response to the changing nature of the COVID-19 pandemic, the CSU was able to provide a flexible approach to delivering the clinics. Reviews were initially offered by telephone, with face-to-face appointments made available (in line with Trust guidelines) as lockdown restrictions eased. During summer 2021, additional clinic slots were released to support the management of the increasing number of diabetes patients needing clinical support.
The pharmacist also supported the wider MDT with queries relating to a range of issues such as pregnancy, learning disabilities, weight management and funding requests. In addition, the pharmacist was able to support the diabetes helpline, providing help and advice in response to patient enquiries.
The specialist clinics have utilised considerable experience, knowledge and expertise, in the management of patients with complex diabetes and hypertension, to deliver flexible and high-quality support for these patient cohorts.
The CSU utilised a tool called MedOptimise® to record interventions, measure patient outcomes and calculate return on investment (without patient identifiable data). In total:
- 704 patient reviews took place
- 1,675 interventions were made (an average of 2.2 per patient)
- 4,509 medications were reviewed which not only improved patient safety but also resulted in 12-month drug savings of £19,432
- 5.3 hospital admissions were prevented with estimated savings of £14,590.
The value of specialist pharmacist-led clinics has been recognised, with the Trust recommissioning the hypertension clinic support for a further 12 months. An in-house pharmacist has been supported to take over the diabetes clinics, following an extensive shadowing process, to ensure its ongoing sustainability.